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Holcomb, David TOT vN OF QUEEMSB 21.qZY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director -'�' Name ���/,//_L/ ✓���,�'`/��/7 Case # Date of Cremat i cn c Time Cremation Started �)';o Time Cremation Completed t- r �e� /7 �u� ► Type of Container %//j Remarks : . w 1 TOWN OF OUEENSBURY pINE VIEW CEMETERY CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone (518) Crematorium 774-44776or if no answer Cemetery AUTHORIZATION TO CREMATE The undersigned requests and authorizes Pine View Crematorium, in accordance with and subject to its Rules and Regulations to ' mate, the e r e p s�i n s o f e S C 11 (Sex) (Name) �� 11�YJ OStat � (Zip Code) (Street ) (City) l day of 19 who died on � at �\ (place) (Address) Name and address of nearest living relative or name of , person authorizing cremati;nCJ'�1' `�-� (Name) (Address) Relationship to the deceased 777)�T _ 1^ Name of Funeral Home IMPURTANT3 knowled a the deceased has or sent that to the best of my (Circle One) has no acemaker in his or her body. I certify that I have the full power and authorization to arrange ion Of for the cremation of the remains ersonal d to di possessionsrect the shave teither the cremated remains, that any p defend been removed or may be destroyed, and agree to protect, and save harmless Pine View Crematorium from any and all claims or damages which may be made again and demands for loss st them by reason of or conthernsuchdclaims or with e demandsoareoorsaare notawholly directed, whether groundless, false or fraudulent. (Witness) (Address) ( (Sig ure of Relativ or Legal Rep. and Address) Sgned on this dates DISPOSITION OF CREMATED REMAINS I hereby direct Pine View Crematorium to dispose of the cremated remains as follows : Mail to Other arrangements - please specify: If pulverization of cremate remains is requested, check here POLICIES, RULES AND REGULATIONS 1 . The crematorium will be open for cremations 5 days a week 7 : 00 A.M. - 3 : 30 P.M. Monday-Friday. No Holidays or Sundays, arrangements can be made for Saturday. Prearrangements by telephone for acceptance of remains is necessary. * 2 . Pine View Crematorium is located on the grounds of the Pine View Cemetery, Quaker Road, Town of Queensbury. 3 . An authorization for cremation properly signed by the nearest next of kin or other authorized person stating that they do have the power and authority to arrange for the cremation of the remains and to direct the disposition of the cremated remains, that any personal possessions have either been removed or may be destroyed and agree to protect, defend and save harmless Pine View Crematorium from any and all claims and demands for loss of damages which may be made against them by reason of or connected with the cremation; of said remains and/or disposition of said remains as directed, whether such claims or demands are, or are not wholly groundless, false or fraudulent. This authorization in addition to a regular burial permit must accompany the remains . 4 . All remains must be encased in a casket or suitable alternate container. Caskets and containers must be of combustible material. No styrafoam or plastic containers will be accepted. 5 . The question relative to cardiac pacemakers must be answered on the authorization to cremate form before the remains will be accepted. 6 . Unless other arrangements are made the cremated remains will be mailed via Registered U. S. Mail within three days of cremation to the funeral home handling the service. There will be a $20 . 00 charge for this service. Cremation, Administration Costs and Recording Fee: Adult $195.00 Children (age 13 months to 12 years) $115 . 00 Infants (stillborn to 12 months ) $75 .00 * Additional $50. 00 charge for cremations done after 3 :00 P.M. Monday through Friday. Cremations done on Saturdays will be charged the additional $50 . 00. Y 1A -A "Customer's Designation of Intentions" Name of Deceased: r C Cremation. 14 ( .dula Date) (Location) Manner of Disposition of Cremated Remains: 0 Returu J( Burial at to Family El Entombment at 0 Other (specify): i hereby designate the Disposition of Cremated Remains and acluiowledge receipt of a copy of this form. 4� (Signature) V (Printed N—.),_.) (Relationship to Deceased) lyl, (Address) v- (r.leph..Number) "Cremated Remains which shall not have been claimed within 12o days from the date of cremation may be disposed of by this firm by placement in a columbarium." X,ry Printed Da ,une of Funeral Director Signfhlre of Funeral Director or Undertaker or Undertaker TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS Cremation: (Actual Date) (Location of Crematory) Disposition of Cremated Remains: (Manner of Disposition) (Location) (Date) Name of Person Making Disposition Signature Date #9 wHrm Funeral H.copy YE110W Family Copy PINK:crematory COPY CUSR-ffEN Rev.V96 F t ATTACH BOOKLET AL"ORIZATION FOR CREMATION AND DISPOSITION HERE NOS THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING I/We,the undersigned, certi{y�o rrant and represent that I/we have the f 4 legal right and authority to authorize the disposition of the rema cremation,processing and iis • ''a (hereinafter referred to as the"Deceased"). ame o D r--� Date of Death V �� Time of Death J ? ❑A.M.�P.M. I/We hereby request and authoriz v• I Y'l� `{ .j � (hereinafter referred to as the `Funeral Home")to Name ot Fanerdl Home tape possession of and make arrangements for the cremation of the remains of the Deceased at (hereinafter referred to as the"Crematory"). Name c&Crematory I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and custodyof theFuneral Home. L understand that the services and obligations of the Crematory shall be fulfilled when th cremated of theDeceased are returned to the possession and custody of the Funeral Home. I/We hereby authorize the Funeral Home to arrange for the disposition of the cremated remains of the Deceased as follows: Is special handling required? El Yes �No Describe Description of urn or container selected: Suitable for sbipping: es ❑No Deliver to F R y t . Cemetery ❑ Release to family ';3 Name Address of Cemetery Name of Designated Family Member to Receive Cremated Remains ❑ Scattering at sea by Funeral Home or Funeral Home's agent ❑ Ship via_U.S. Registered Mail* To: Name: Address: ❑ Other Funeral Home and Crematory are not responsible for any loss or damage of cremated remains shipped via Registered Mail with the United States Postal Service. The cremation, processing and disposition of the remains of the Deceased authorized herein shall he performed in accordance with all governing laws,the rules,regulations and policies of the Crematory and Funeral Home, and the following terms and conditions: 1. The remains of the Deceased will not be accepted for cremation unless received by the Crematory in a combustible, leak resistant, rigid cremation container. The Crematory is authorized to remove and dispose of handles, ornaments and any other noncombustible items attached to the cremation container prior to cremation. In the event the remains of the Deceased are received by the Crematory in a casket or other container constructed of metal, fiberglass, or other noncombustible materials, I/we authorize the remains of the Deceased to be removed prior to cremation and placed in a combustible cremation container I/We further authorize the Funeral Home or Crematory to make disposition of any such noncombustible casket in any lawful manner it deems appropriate. 2. Mechanical or radioactive devices implanted in the remains of the Deceased (such as pacemakers, etc.) may create a hazard when placed in the cremation chamber. The Crematory will not cremate any human remains which contain any tyype of imQlanted mechanical or radioactive device. In the event the remains of the Deceased contain such a device, I/we hereby authorize the Funeral Home, its agents and employees, to remove any such mechanical devices from the remains of the Deceased prior to cremation, and dispose of such items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED DO = DO NOT "CONTAIN ANY TYPE OF IMPLANTED MECHANICAL,OR RADIOACTIVE DEVICE. Please initial one. Listed below are all implanted mechanical and radioactive devices which the Funeral Home is authorized to remove from the remains of the Deceased prior to cremation,and dispose of as indicated: Description of Implanted Device Disposition Description of Implanted Device Disposition If no instruction for disposition is given,such items may be disposed of at the discretion of the Funeral Home. 3. The cremation container containing the remains of the Deceased will he placed in the cremation chamber and will be totally and irreversihly destroyed by prolonged exposure to intense heat and direct flame. I/We authorize the Crematory to open the cremation chamber during the cremation process and reposition the remains of the Deceased in order to facilitate a complete and thorough cremation. 4. Certain items, including, but not limited to, body prostheses, dentures, dental bridgework, dental fillings, jewelry, and other personal articles accompanying the remains of the Deceased, may he destroyed during the cremation process. I/We further authorize that if any items, other than the cremated remains of the Deceased, are recovered from the cremation chamber, they may he separated from the cremated remains of the Deceased and disposed of by the Crematory. to $ n�limitedytouhingese the latches,nCrematory iler jewelry and precarate ious ue metalremove hsom the cremation and to dispose of suchmaterials. er all noncombustible materials, including, but 6. Following cremation, the cremated remains of the Deceased, consisting primarily of hone fragments, will be mechanically pulverized to an unidentifiable consistency prior to placement in an urn or other container. 7. Unless an urn or container suitable for shipment is purchased, the Crematory will place the cremated remains of the Deceased in a container which is not designed for any type of shipment. 8. In the event the urn or container is insufficient to accommodate all of the cremated remains of the Deceased, any excess cremated XR ; AUTHORIZATION FOR CREMATION AND DISPOS�ION F,THIS ISA EGAL DOCUMENT. ITCONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. ATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING ned, certify,warrant and represent that I/we have the legal right and authority to authorize the cremation rocessing isposition of the remainso f (hereinafter referred to as the"Deceased")d <^ Date of Death ' C) r 3(i Tune of Death 7 ❑AM. PM. I/We hereby request and authorize u, - ' (hereinafter referred to as the"Funeral Home')to Name of Funeral Home f take possession of and make arrangements for the cremation of the remains of the Deceased at (hereinafter referred to as the"Crematory"). Name Of Crematory I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and custod of the Funeral Home. I/we understand that the services and obligations of the Crematory shall be fulfilled when the cremated remains of the Deceased are returned to the possession and custody of the Funeral Home. I/We hereby authorize the Funeral Home to arrange for the disposition of the cremated remains of the Deceased as follows: Is special handling required? ❑Yes ❑ No Describe Description of urn or container selected: Suitable for shipping: es ❑No Deliver to )% -. r Cemetery ❑ Release to family an Name Address of Cemetery Name of Designated Family Member to Receive Cremated Remains ❑ Scattering at sea by Funeral Home or Funeral Home's agent ❑ Ship via U.S. Registered Mail To: Name: Address: ❑ Other Funeral Home and Crematory are not responsible for any loss or damage of cremated remains shipped via Registered Mail with the United States Postal Service. The cremation/ processing and disposition of the remains of the Deceased authorized herein shall be performed in accordance with all governing laws,t]ie rules,regulations and policies of the Crematory and Funeral Home,and the following terms and conditions: I. The remains of the Deceased will not he accepted for cremation unless received by the Crematory in a combustible, leak resistant, rigid cremation container. The Crematory is authorized to remove and dispose of handles, ornaments and any other noncombustible items attached to the cremation container prior to cremation. In the event the remains of the Deceased are received by the Crematory in a casket or other container constructed of metal, fiberglass, or other noncumbustible materials, I/we authorize the remains of the Deceased to be removed prior to cremation and placed in a combustible cremation container. I/We further authorize the Funeral Home or Crematory to make disposition of any such noncombustible casket in any lawful manner it deems appropriate. 2. Mechanical or radioactive devices implanted in the remains of the Deceased (such as pacemakers, etc.) may create a hazard when placed in the cremation chamber. The Crematory will not cremate any human remains which contain any type of implanted mechanical or radioactive device. In the event the remains of the Deceased contain such a device, I/we hereby authorize the Funeral Home, its agents and employees, to remove any such mechanical devices from the remains of the Deceased prior to cremation, and dispose of such items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED DO 0 DO NOT �ONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE. Please initial one. Listed below are all implanted mechanical and radioactive devices which the Funeral Home is authorized to remove from the remains of the Deceased prior to cremation,and dispose of as indicated: Description of Implanted Device Disposition .16vlanted Device Disposition If no instruction for disposition is given,such items may be disposed of at the discretion of the Funeral Home. 3. The cremation container containing the remains of the Deceased will be placed in the cremation chamber and will be totally and irreversibly destroyed by prolonged exposure to intense heat and direct flame. I/We authorize the Crematory to open the cremation chamber during the cremation process and reposition the remains of the Deceased in order to facilitate a complete and thorough cremation. 4. Certain items, including, but not limited to, body prostheses, dentures, dental bridgework, dental fillings, jewelry, and other personal articles accompanying the remains of the Deceased, may be destroyed during the cremation process. I/We further authorize that if any items, other than the cremated remains of the Deceased, are recovered from the cremation chamber, they may be separated from the cremated remains of the Deceased and disposed of by the Crematory. We 5. not Jimit bd to,authorize, binges,latchesCrematory nails,jewelr to y and precarate ious metals remove , and tom the dispose of such materials.on chamber noncombustible materials, including, but 6. Following cremation, the cremated remains of the Deceased, consisting primarily of bone fragments, will be mechanically pulverized to an unidentifiable consistency prior to placement in an urn or other container. 7. Unless an urn or container suitable for shipment is purchased, the Crematory will place the cremated remains of the Deceased in a container which is not designed for any type of shipment. 8. In the event the urn or container is insufficient to accommodate all of the cremated remains of the Deceased. anv exve-sA cremate